Persistent Common Bile Duct Stones Research Articles

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review.

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically reviewthe outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool. Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Prevalence of Persistent Common Bile Duct Stones in Acute Biliary Pancreatitis Remains Stable Within the First Week of Symptoms

BackgroundAcute biliary pancreatitis (ABP) is often associated with persistent common bile duct (CBD) stones. The best strategy in terms of timing of surgery is still controversial. The aim of the current study is to describe the prevalence of persistent common bile duct (CBD) stones in ABP during the first week of symptoms at a high-volume referral center. Study DesignSingle-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of ABP who underwent laparoscopic cholecystectomy (LC) between January 2009 and December 2019 were extracted. ResultsTwo hundred thirty-one patients were included. Cholecystectomy was performed laparoscopically in 230 (99.57%) patients. Intraoperative cholangiogram was performed in all patients. Two hundred nine (90%) patients had surgery within the first 7 days. Global prevalence of persistent CBD stones during IOC was 19.91% (95% CI 14.96–25.65). No significant association between timing to surgery and presence of CBD stones was found for the first week since the initial attack (p=0.28). Prevalence of CBD stones was significantly higher after day 7 (p=0.007 and 0.005). Positive findings in preoperative MRCP are significantly related to intraoperative CBD stones (p=0.0001). Mild postoperative complications (CD I/II) were present in 21 patients (9.09%). No difference was found in morbidity between CBD stones group and non-CBD stones group (p=0.48). We observed no severe complications nor mortality. ConclusionsIn patients with mild acute biliary pancreatitis, the prevalence of persistent CBD stones does not change within the first 7 days since the onset of symptoms. This fact may have major clinical relevance when deciding the optimal therapeutic strategy in this population.

Predictors of persistent common bile duct stones in mild acute biliary pancreatitis; the role of liver enzyme and dilated CBD on ultrasound

Background: Abnormal liver enzyme tests (LET) are frequent in acute biliary pancreatitis (ABP), and not always related to persistent common bile duct stones (CBDS). The aim of our study was to determine whether LET on admission, value variations at 24 h and dilated common bile duct (CBD) on ultrasound (US) are appropriate predictors of CBDS in mild ABP. Methods: Data were analysed from our prospective database of 56 consecutive patients diagnosed of mild ABP; of whom 14(25%) had persistent CBDS confirmed by endoscopic retrograde cholangio-pancreatography. LET; alanin aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) on admission and at 24 h were evaluated. Higher LET values were considered: TB>1.2mg/dl, AST>75U/l, ALT>75U/l. Abdominal US was performed. Predictive accuracy of the variables was measured using area-under-the-receiver-operating characteristic curve (AUC) analysis. Results: Neither abnormal LET on admission or its raised values at 24h showed accuracy in predicting CBDS (AUC values under 0.5), nor did the association of the 3 abnormal LET (AUC=0.66; 0.51-0.82). However, dilated CBD on US showed good accuracy for predicting CBDS (AUC=0.75; 0.58-0.91). Conclusion: A dilated CBD on US seems to be superior than abnormal LET in predicting CBDS in mild ABP, it could help to guide decisions making in the emergency setting of mild ABP, on selection of patients who will benefit from other specific imaging techniques.

Predictors of persistent common bile duct stones in mild acute biliary pancreatitis; the role of liver enzyme and dilated CBD on ultrasound

Background: Abnormal liver enzyme tests (LET) are frequent in acute biliary pancreatitis (ABP), and not always related to persistent common bile duct stones (CBDS). The aim of our study was to determine whether LET on admission, value variations at 24 h and dilated common bile duct (CBD) on ultrasound (US) are appropriate predictors of CBDS in mild ABP. Methods: Data were analysed from our prospective database of 56 consecutive patients diagnosed of mild ABP; of whom 14(25%) had persistent CBDS confirmed by endoscopic retrograde cholangio-pancreatography. LET; alanin aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) on admission and at 24 h were evaluated. Higher LET values were considered: TB>1.2mg/dl, AST>75U/l, ALT>75U/l. Abdominal US was performed. Predictive accuracy of the variables was measured using area-under-the-receiver-operating characteristic curve (AUC) analysis. Results: Neither abnormal LET on admission or its raised values at 24h showed accuracy in predicting CBDS (AUC values under 0.5), nor did the association of the 3 abnormal LET (AUC=0.66; 0.51-0.82). However, dilated CBD on US showed good accuracy for predicting CBDS (AUC=0.75; 0.58-0.91). Conclusion: A dilated CBD on US seems to be superior than abnormal LET in predicting CBDS in mild ABP, it could help to guide decisions making in the emergency setting of mild ABP, on selection of patients who will benefit from other specific imaging techniques.

Management of biliary acute pancreatitis

Acute pancreatitis is a frequent pathology with 11,000 to 13,000 new cases per year in France. A biliary origin (30 to 70% of the cases) should be suspected when alanine amino-transferases are elevated during the first 48 hours, and it is confirmed by the presence of gallstones at trans abdominal ultrasound. Abdominal computed-tomography scan is performed around the fifth day, and is repeated according to clinical and biological evolution. Management of acute biliary pancreatitis varies according to its severity, which should be assessed according to systemic inflammatory response syndrome and organ failures. For mild acute pancreatitis, cholecystectomy should be performed during in-hospital stay, before oral feeding. For moderately severe and severe acute pancreatitis, treatment is based on resuscitation, early enteral continuous feeding, and management of complications. Interval cholecystectomy is performed at a later stage. Endoscopic retrograde cholangiopancreatography with sphincterotomy should be performed in emergency when angiocholitis is associated, and in delayed emergency before oral feeding for persistent common bile duct stone. A common bile duct stone should be searched for during cholecystectomy and can be treated during the same surgical procedure if local conditions are adequate. Cholelithiasis is the most frequent cause of acute pancreatitis during pregnancy, and its diagnosis and the treatment have some particularities.

Gallstone Pancreatitis and Choledocholithiasis: Using Imaging and Laboratory Trends to Predict the Likelihood of Persistent Stones at Cholangiography.

Patients with gallstone pancreatitis (GP) or choledocholithiasis (CDL) may have common bile duct (CBD) stones that persist until cholangiography. The aim of this study is to evaluate pre-cholangiogram factors that predict persistent CBD stones. Multiple logistic regression analyses were performed to identify demographic, laboratory, and radiologic predictors of persistent CBD stones and non-therapeutic cholangiography among adults with GP or CDL. In 152 patients from 2010 to 2015, preoperative diagnosis, presence of a CBD stone on US, and age ≥ 60years were associated with persistent CBD stones. Two risk factors alone had a PPV of 88% and the absence of all risk factors had a NPV of 94%. Age < 60years and the absence of a CBD stone on US were most predictive of non-therapeutic cholangiography. Age, LFTs, and US help predict persistent CBD stones in patients initially presenting with GP or CDL and help minimize non-therapeutic preoperative cholangiography.

Dynamic analysis of commonly used biochemical parameters to predict common bile duct stones in patients undergoing laparoscopic cholecystectomy.

The prediction of persistent common bile duct stones (CBDS) in patients during choledocholithiasis crisis is challenging. We developed a model based on the course over time of commonly used biochemical parameters to reduce the rate of unnecessary endoscopic cholangiopancreatography (ERCP) and the risk of perioperative discovery of CBDS. Medical charts of patients who presented between 2010 and 2015 for symptomatic gallstone disease with suspected choledocholithiasis were reviewed and compared according to the presence/absence of CBDS on preoperative ERCP or during cholecystectomy. 210 patients were included. Unnecessary ERCP and the discovery rate of CBDS were 9.0 and 22.4%, respectively. Multivariate analysis demonstrated age ≥80years, neutrophils ≥12000/µL and gamma-glutamyl transpeptidase (GGT) ≥300units/L at admission, alkaline phosphatase ≥180units/L at days 3-5 post admission, and a decrease in C-reactive protein ≤10%, aspartate aminotransferase ≤35%, GGT ≤25%, and total bilirubin ≤15% between day 0 and days 3-5 to be predictive of CBDS. The area under the receiver-operator characteristic curve was 0.881. When used to select patients for preoperative ERCP, diagnostic accuracy was 94.8% when three predictors were present. Negative and positive predictive values were 100% in the absence of predictors and when five predictors were present, respectively. Unnecessary ERCP and CBDS discovery rates both decreased to 2.6%. Commonly used biochemical parameters correctly predict CBDS when they are analysed in a dynamic setting rather than at discrete time points. The proposed model constitutes a reliable tool to decrease unnecessary ERCP and perioperative discovery rates of CBDS.

Does presence of common bile duct stones in patients with acute biliary pancreatitis affect the severity of illness or laboratory findings?

To determine the effect of stone within the common bile duct, on the severity of acute biliary pancreatitis. This is a prospective and cross sectional study which was conducted at a tertiary care hospital including 103 patients. Serum biochemical values and white blood cell counts at the first 12th and 72nd hours of presentation were evaluated. The patients were grouped according to the presence or absence of common bile duct stones which were diagnosed by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Besides, the patients were classified as mild and severe acute pancreatitis according to the data provided by computed tomography (Balthazar scoring) and clinical assessment and blood samples. Among the 103 patients with acute biliary patients, radial endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography revealed stones and/or sludge within the common bile duct or ampulla in 41 (39.8%) patients. There was not any persistent common bile duct stone in 62 (60.2%) patients. Severe pancreatitis developed in 9 (22%) of 41 patients who were determined to have stones by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, and in 13 (21%) of 62 patients who were not. There was no difference in the incidence of progressing to severe acute biliary patients between patients with and without common bile duct stones (p=0.45). Presence of common bile duct stones do not correlate with the severity of acute biliary pancreatitis.

Selective Management of Patients with Acute Biliary Pancreatitis

BackgroundDetection of common bile duct (CBD) stones in patients with acute biliary pancreatitis (ABP) proves challenging. We hypothesized that grouping clinically significant predictors would increase reliability of detection. MethodsA retrospective review was performed of 144 consecutive patients who presented to a single tertiary care institution from 2002 to 2007 with ABP. ResultsOf the 144 patients, 32 had a persistent CBD stone. Following multivariate analysis, admission CBD size on ultrasound, gamma glutamyl transferase (GGT), alkaline phosphatase (AP), total bilirubin (TB), and direct bilirubin (DB) significantly correlated with persistent CBD stone. Receiver operator curve analysis and linear regression were applied to obtain optimal and equitable predictive values, and variables combined. Optimal values were: CBD ≥ 9 mm; AP ≥ 250 U/l; GGT ≥ 350 U/l; TB ≥ 3 mg/dl; and DB ≥ 2 mg/dl. Presence of five variables had an associated odds ratio (OR) of 53.1 (p < 0.001) and four variables an OR of 8.97 (p = 0.004) for presence of persistent CBD stone. Zero variables conferred a significantly decreased probability of CBD stone, OR 0.15 (p < 0.001). Presence of one to three variables did not predict presence of CBD stone. ConclusionPresence of four or five variables significantly correlated with persistent CBD stone. Biliary evaluation by endoscopic retrograde cholangiopancreatography is suggested, as initial magnetic resonance cholangiopancreatography (MRCP) may only increase cost and delay time to intervention. In the absence of any variable, biliary evaluation by intraoperative cholangiogram may be sufficient. Decisions regarding patients with one to three variables should occur on a case-to-case basis. Initial biliary evaluation by MRCP is likely preferable, however, as no increased probability of CBD stone was identified, thus not warranting risks associated with intervention.

Are there roles for intraductal US and saline solution irrigation in ensuring complete clearance of common bile duct stones?

Persistent small common bile duct (CBD) stones after endoscopic sphincterotomy (EST) and stone extraction may be a nidus for stone growth and could be detected by intraductal US (IDUS). CBD saline solution irrigation may flush out residual stones. Our purpose was to determine the frequency of residual CBD stones after EST and basket/balloon extraction by using IDUS and to assess the effectiveness of saline solution irrigation in clearing remnant CBD stones. Prospective study. General Hospital Singapore. Seventy patients (mean age 62 years, 51% male) were recruited. In the presence of CBD stones, EST and stone extraction were performed, followed by IDUS. If residual stones were detected, a catheter was inserted into the proximal CBD, saline solution irrigation performed, and IDUS repeated. (1) The frequency of residual stones detected by IDUS after EST and basket/balloon extraction and (2) the effect of saline solution irrigation in clearing residual CBD stones. Cholangiogram showed CBD stones in 38 of 70 patients (median 1 [range 1-5], mean size 7.6 mm [range 3.0-12.0 mm]). IDUS showed CBD stones in 32 of 32 with normal cholangiogram (median 2 [range 1-8], mean size 2.6 mm [range 0.9-7.2 mm]). After EST and stone extraction, IDUS showed persistent stones in 28 of 70 (median: 2 [range 1-5], mean size 2.2 mm [range 1.1-4.6 mm]). The CBD was irrigated with a mean of 48 mL of saline solution. Repeat IDUS showed persistent CBD stones in 2 of 70, and these were flushed out by further saline solution irrigation. Single-center study. IDUS detected small residual CBD stones that persisted after EST and basket/balloon extraction. Saline solution irrigation appeared useful in clearing residual small stones.

Refining the Indications for ERCP in Biliary Pancreatitis

According to a guideline from the American Gastroenterological Association, “ERCP [endoscopic retrograde cholangiopancreatography] should be urgently performed when acute cholangitis has complicated acute biliary pancreatitis [. . . and] when clinical or radiographic features suggest a persistent common bile duct stone.” For patients without these findings — but with pancreatitis …

AGA Institute Medical Position Statement on Acute Pancreatitis

AGA Institute Medical Position Statement on Acute Pancreatitis

Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends.

We aimed to determine whether early trends in the serum pancreatic enzymes and liver tests of patients with gallstone pancreatitis predict persistent common bile duct (CBD) stones and complications. Medical records of patients with gallstone pancreatitis were reviewed retrospectively. Serial serum pancreatic enzymes and liver tests were recorded until the time of cholangiography. Laboratory trends were analyzed by comparing initial results obtained in the emergency department to subsequent results obtained 8-24 h, 24-48 h, and 48-72 h after presentation. Of 154 patients with gallstone pancreatitis, 28 (18%) had persistent CBD stones at cholangiography. Complications and death were more frequent in patients with persistent CBD stones than in those without CBD stones (29% and 11% vs 12% and 1%, respectively; p < 0.05). Laboratory trends predicted both persistent CBD stones and complications of pancreatitis. When any laboratory value rose between admission and 24-48 h of hospitalization, persistent CBD stones were present in 31% of cases, versus 8% of those in whom all laboratory values remained constant or fell (p = 0.001). Likewise, complications occurred in 21% of those with any rising laboratory value, versus 8% of those in whom all values remained constant or fell (p < 0.05). Patients with gallstone pancreatitis and rising serum chemistries had a 4-fold risk of persistent CBD stones and a nearly 3-fold risk of complications compared to patients in whom all chemistry values remained constant or fell. This simple prediction rule may identify patients with biliary pancreatitis who are most likely to benefit from early interventions to diagnose and remove persistent CBD stones.

Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends

OBJECTIVES: We aimed to determine whether early trends in the serum pancreatic enzymes and liver tests of patients with gallstone pancreatitis predict persistent common bile duct (CBD) stones and complications. METHODS: Medical records of patients with gallstone pancreatitis were reviewed retrospectively. Serial serum pancreatic enzymes and liver tests were recorded until the time of cholangiography. Laboratory trends were analyzed by comparing initial results obtained in the emergency department to subsequent results obtained 8–24 h, 24–48 h, and 48–72 h after presentation. RESULTS: Of 154 patients with gallstone pancreatitis, 28 (18%) had persistent CBD stones at cholangiography. Complications and death were more frequent in patients with persistent CBD stones than in those without CBD stones (29% and 11% vs 12% and 1%, respectively; p < 0.05). Laboratory trends predicted both persistent CBD stones and complications of pancreatitis. When any laboratory value rose between admission and 24–48 h of hospitalization, persistent CBD stones were present in 31% of cases, versus 8% of those in whom all laboratory values remained constant or fell ( p = 0.001). Likewise, complications occurred in 21% of those with any rising laboratory value, versus 8% of those in whom all values remained constant or fell ( p < 0.05). CONCLUSIONS: Patients with gallstone pancreatitis and rising serum chemistries had a 4-fold risk of persistent CBD stones and a nearly 3-fold risk of complications compared to patients in whom all chemistry values remained constant or fell. This simple prediction rule may identify patients with biliary pancreatitis who are most likely to benefit from early interventions to diagnose and remove persistent CBD stones.

Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.

The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

Gallstone Pancreatitis: A Prospective Study on the Incidence of Cholangitis and Clinical Predictors of Retained Common Bile Duct Stones

Objective: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). Methods: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Results: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. Conclusion: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.